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J Neurosurg Case Lessons
J Neurosurg Case Lessons
J Neurosurg Case Lessons
Journal of Neurosurgery: Case Lessons
2694-1902
American Association of Neurological Surgeons

39250832
10.3171/CASE24434
CASE24434
AnatomyAnatomyInfectionInfectionSpineSpineLumbarLumbarCase Lesson
Lumbar laminectomy and washout of emphysematous osteomyelitis infection of the spine: illustrative case
Rajjoub Rami BS 1
Dedhia Mehek BA 1
Jones Salazar MD 1
1 Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
Correspondence Salazar Jones: Icahn School of Medicine at Mount Sinai, New York, NY. salazar.jones@mountsinai.org.
INCLUDE WHEN CITING Published September 9, 2024; DOI: 10.3171/CASE24434.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.xs

09 9 2024
09 9 2024
8 11 CASE2443404 7 2024
19 7 2024
© 2024 the authors
2024
the authors
https://creativecommons.org/licenses/by-nc-nd/4.0/ CC BY-NC-ND 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/)

BACKGROUND

Emphysematous osteomyelitis (EO) is a rare, rapidly progressing infection characterized by gas within bones, leading to severe morbidity if untreated. In the spine, EO can cause significant bone destruction and instability, requiring urgent surgical and medical intervention. Early diagnosis and a multidisciplinary approach are crucial for effective management and improved patient outcomes.

OBSERVATIONS

The authors present a unique case of EO involving the lumbar spine in a 40-year-old male patient with a medical history of diabetes mellitus, hyperlipidemia, and hypertension. Magnetic resonance imaging and computed tomography revealed the formation of gas within the L4 vertebral body and spinal canal, which led to the diagnosis of EO. Blood cultures grew Streptococcus dysgalactiae. The patient underwent laminectomy, discectomy, and vertebral body abscess washout to prevent further spread of the infection and successfully recovered.

LESSONS

The authors report the first case of spinal EO caused by S. dysgalactiae, treated using laminectomy with debridement of the affected disc spaces.

https://thejns.org/doi/10.3171/CASE24434

osteomyelitis
laminectomy
infection
case report
ABBREVIATIONS

BKA = below-knee amputation
CRP = C-reactive protein
CT = computed tomography
EO = emphysematous osteomyelitis
ESR = erythrocyte sedimentation rate
MRI = magnetic resonance imaging
SDSD = S. dysgalactiae subspecies dysgalactiae
SDSE = S. dysgalactiae subspecies equisimilis
WBC = white blood cell.
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pmcEmphysematous osteomyelitis (EO) is a rare but rapidly progressing condition characterized by the presence of intraosseous gas within the axial and appendicular skeleton.1 EO was first reported in 1981 when computed tomography (CT) scans revealed intraosseous gas in the medullary cavities of the femur, tibia, and fibula in three patients.2 Since then, there have been a limited number of case reports that have described EO formation within the vertebral bodies.1, 3 With respect to interventions, studies have recommended using a surgical approach for patients who present with neurological deficits, sepsis, spinal instability, and progressive spinal deformity as a result of vertebral body destruction.4 Here, we present the case of a 40-year-old male with EO of the lumbar spine caused by Streptococcus dysgalactiae.

Illustrative Case

A 40-year-old male presented to the emergency department of a level 1 trauma hospital with a new ulcer on the plantar aspect of his right foot, which had been draining purulent and serosanguineous fluid, accompanied by 2 days of excessive fatigue and sleepiness. The patient’s vital signs were as follows: temperature 37.5°C, pulse rate 121 bpm, respiratory rate 17 bpm, and blood pressure 127/75 mm Hg. His body mass index was 21.47 kg/m2. His past medical history was significant for diabetes mellitus (hemoglobin A1C 9.4%), hyperlipidemia, and hypertension. Initial laboratory results indicated elevated glucose levels (220 mg/dL) and neutrophilic leukocytosis (white blood cell [WBC] count 11.0 × 103/μL). The erythrocyte sedimentation rate (ESR) was 86 mm/hr, and C-reactive protein (CRP) was 288 mg/L. The patient had no significant family history.

Initial CT of the right lower extremity showed gas gangrene, which prompted the initiation of a planned 3-day course of Zosyn and a 15-day course of vancomycin. A vascular surgery consultant recommended and later performed a right below-knee amputation (BKA) on the 2nd day of admission. Postoperatively, the patient was switched from Zosyn to a 15-day course of meropenem given the onset of a spiking fever. Subsequent blood cultures tested positive for S. dysgalactiae.

On hospital day 5, axial and sagittal CT imaging showed incidental gas formation in the spine, along with edematous changes and an intraosseous abscess (2.2 × 1.1 cm) within the vertebral body of L4 (Fig. 1). Magnetic resonance imaging (MRI) of the lumbar spine showed a solidly enhancing epidural phlegmon at the level of L4–5 and L4 osteomyelitis (Fig. 2). The patient did not have any back or leg symptoms and was initially going to be managed medically after the BKA. However, the patient had persistent fevers and worsening leukocytosis. Thus, it was decided to offer spinal surgery to reduce the infectious burden. FIG. 1. A: Axial CT showing gas formation within the spinal canal and prevertebral space. B: Sagittal CT showing epidural gas formation in the spinal canal from L4 to S2. C: Sagittal CT showing an L4 intraosseous abscess with gas formation. D: Coronal CT showing an L4 intraosseous abscess.

FIG. 2. A: Axial T1-weighted MRI with contrast showing epidural enhancing phlegmonous changes. B: Preoperative sagittal T2-weighted MRI showing L4 vertebral osteomyelitis and L4–5 osteodiscitis.

The patient underwent L4 and L5 laminectomy with debridement of the L4–5 disc space. Furthermore, given the L4 intravertebral body abscess, it was decided to perform a transpedicular aspiration and lavage technique to wash out the abscess. Jamshidi needles were first inserted bilaterally into the L4 pedicles for aspiration and irrigation using the transpedicular route (Fig. 3A). Aspiration from the right pedicle showed normal-appearing blood, whereas the left pedicle had a mixture of blood and pus (Fig. 3B). The intervertebral body washout was performed by irrigating through one Jamshidi needle while simultaneously aspirating through the second. The Jamshidi needles were removed on both sides. A bone void filler (Stimulan, Biocomposites Ltd.) with 1 g vancomycin and 240 mg gentamicin was prepared and inserted into the L4–5 disc space and the L4 pedicle where the Jamshidi needle had been. The patient recovered well postoperatively, with improvements on imaging of the intraosseous abscess and transpedicular tracts (Fig. 4). FIG. 3. A: Transpedicular aspiration of an intravertebral abscess via a Jamshidi needle. B: Aspiration contents with a mixture of pus and blood.

FIG. 4. A: Postoperative sagittal CT showing L4–5 laminectomy and antibiotic bone void filler within the L4–5 disc space. B: Postoperative image showing improvement in the intraosseous abscess and transpedicular tract. C: Postoperative axial CT showing transpedicular tracts. D: Postoperative coronal CT showing a reduction in the L4 intraosseous abscess and antibiotic bone void filler in the L4–5 disc space.

The patient had no neurological or surgical complications following the procedure. Intraoperative cultures confirmed the presence of S. dysgalactiae. Notably, the patient no longer had fevers, and the leukocytosis improved. The treatment plan was transitioned to ceftriaxone for the completion of a 7-week course of antibiotics.

Patient Informed Consent

The necessary patient informed consent was obtained in this study.

Discussion

Observations

EO of the spine has been associated with gas-forming bacteria that have spread to intraosseous regions of vertebral bodies. EO can be difficult to diagnose and requires laboratory analyses of blood counts, blood cultures, neurological examinations, and various imaging modalities in order to confirm.3 In our patient, the elevated ESR, CRP, and WBC count, accompanied by CT and MRI scans that showed intraosseous gas formation within the L4 vertebral body, strongly suggested a diagnosis of EO.

There have only been about 33 reported cases of EO in the spine.1, 3, 5–7 The first report was by Bielecki et al., who detected spinal infections with accompanying intraosseous and intradiscal gas.8 Since then, recent reports and reviews have suggested that there may be predisposing medical comorbidities and factors associated with spinal EO, including diabetes mellitus, neoplasms, and concomitant infections.1, 3 Specifically, patients with poorly controlled diabetes commonly have complications such as osteomyelitis due to immunological defects and vascular dysfunctions that make them susceptible to anaerobic bacteria invasion.9 The past history of diabetes, accompanied by our patient’s foot ulcer that had been draining serosanguineous fluid, may explain the course the infection took.

To the best of our knowledge, we are the first to report the formation of EO following an S. dysgalactiae infection. A recent systematic review indicated that up to 79% of spinal EO cases have been isolated from certain gas-producing microorganisms such as Klebsiella pneumoniae and Escherichia coli.3 S. dysgalactiae, which includes the S. dysgalactiae subspecies dysgalactiae (SDSD) and S. dysgalactiae subspecies equisimilis (SDSE), is recognized as a pathogen in humans.10, 11 While SDSE is known to cause clinical infections in humans, reports of SDSD infecting humans are less common. Notably, all documented cases have resulted in patient survival.10 Both subspecies are implicated in various clinical conditions, from mild infections such as cellulitis to severe infections like bacteremia and septic shock.11 The incidence of S. dysgalactiae infections, particularly bloodstream infections, has been increasing, suggesting a growing role in human infectious diseases.12

Lessons

Surgical drainage, washout, and curettage are the mainstays of surgical treatment of intraosseous or Brodie’s abscesses.13 In severe cases of vertebral osteomyelitis with bony destruction of the anterior column, anterior surgical debridement and reconstruction are well established. The vertebral body abscess presents challenges in the extent of debridement achievable when the surrounding cortical bone and vertebral height are maintained. Transpedicular vertebral body bone marrow washout is a technique that has been used in treating multiple myeloma.14 We similarly used a transpedicular approach to aspirate an intraosseous abscess, followed by vertebral body irrigation. Our patient went on to have successful eradication of his infection without relapse or the need for further spinal procedures. In conclusion, S. dysgalactiae is a pathogen that has to be increasingly recognized in the management of osseous infections. We presented the first reported case of vertebral EO by S. dysgalactiae and a minimally invasive technique to target an intraosseous abscess.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Jones, Rajjoub. Acquisition of data: all authors. Analysis and interpretation of data: Jones, Rajjoub. Drafting the article: Jones, Rajjoub. Critically revising the article: Jones, Dedhia. Reviewed submitted version of manuscript: Jones, Dedhia. Approved the final version of the manuscript on behalf of all authors: Jones. Study supervision: Jones.

Correspondence

Salazar Jones: Icahn School of Medicine at Mount Sinai, New York, NY. salazar.jones@mountsinai.org.
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